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Getting Ready for Wound Certification: Assessment and Management of Atypical Wounds

Simmons, Jessica

Journal of Wound Ostomy & Continence Nursing: September/October 2018 - Volume 45 - Issue 5 - p 474–476
doi: 10.1097/WON.0000000000000464
Getting Ready for Certification

Jessica Simmons, MSN, APN, FNP-C, CWON, DNC, Swedish American Health System Rockford, Illinois.

Correspondence: WOCNCB 555 East Wells Street Suite 1100, Milwaukee, WI 53202-3823 (info@wocncb.org).

The author declares no conflicts of interest.

While many wounds can be classified based on their etiologies, such as neuropathy, vascular insufficiency, and prolonged pressure, not all wounds fall neatly into these categories. It is estimated that approximately 10% of chronic leg wounds are considered atypical, meaning they are the result of an etiology other than pressure, neuropathy, or vascular insufficiency.1 Underlying pathologic conditions that can contribute to the development of atypical wounds include infection, malignancy, inflammatory disease, renal disease, allergic response, and trauma.

While the eyes may be the window to one's soul, the skin can be viewed as the window to one's state of health. Changes in skin condition often provide clues to a patient's overall wellness. Inflammatory diseases are an excellent example. After an acute injury, inflammation is a vital response toward wound healing. When inflammation appears, it can precipitate ulcerative conditions such as vasculitis and pyoderma gangrenosum or skin disorders such as bullous pemphigoid and psoriasis. For example, small vessel inflammation, as seen in vasculitis, can damage vascular tissue and present as purpuric papules. As the damaged vessels become necrotic, hemorrhagic bullae with ulceration will develop.2 Acute inflammatory conditions such as Stevens-Johnson syndrome/toxic epidermal necrolysis and allergic contact dermatitis generate a T-cell–mediated response affecting the epidermis and dermis causing epidermal loss.3

The WOCNCB wound care certified nurse must be well versed in not only wounds caused by pressure, venous insufficiency, and arterial or neuropathic disease but also wounds considered to be atypical. Comprehensive assessment of all wounds, and especially atypical wounds, is essential when developing a treatment plan.4 If an atypical wound is suspected, it is critical to gather a thorough patient history. Careful attention should be paid to the history of the wound as well as other aspects of the patient's history: medical, surgical, social, and family history, medications, and allergies. For example, recent use of trimethoprim/sulfamethoxazole (Bactrim) for a urinary tract infection would be a highly suspicious causative factor in a patient with extensive dermal loss with possible Steven-Johnson syndrome. When conducting a physical exam, one must look for clues in the patient's clinical presentation. A history of renal disease combined with painful violaceous hued lesions over their upper legs should raise suspicion for calciphylaxis.4 Close attention must be paid to the wound's location, depth, condition of the wound bed, shape, margins, and surrounding tissue. Atypical wounds often have an unusual presentation. Pyoderma gangrenosum may present with characteristic superficial wounds with necrotic wound beds and irregular, raised, violaceous margins. As atypical wounds are a symptom of an underlying condition, observation of the distribution of the wound or wounds may signal systemic pathology.

Atypical wounds are often a challenge when determining etiology. The cause of these wounds can be unclear or mimic other etiologies. When the underlying etiology of the wound is unclear, further diagnostic testing such as vascular testing, imaging, labs, cultures, and biopsies are needed to rule out other conditions such as malignancy. When wounds are slow or nonhealing, it is reasonable to reconsider the initial diagnosis and explore other etiologies and thus a biopsy may be needed.1 However, conditions like pyoderma gangrenosum may reveal nonspecific findings on the pathology report of a tissue sample.4

A holistic approach is needed to manage atypical wounds. In addition to appropriate wound care, patients with atypical wounds need careful management of the underlying causative condition. The focus of care with atypical wounds may be more supportive care, with treatment goals of preventing infection and further trauma, minimizing pain, managing drainage and odor, and providing a moist wound-healing environment. For example, when caring for a patient with epidermal sloughing from Staphylococcus-scalded skin syndrome or graft versus host disease, topical management utilizing nonadherent absorbent dressings, contact layers, and antimicrobials should be considered.3 , 5 Selection of supportive surfaces to redistribute pressure, address microclimate, and reduce friction/shear is another therapeutic method.3 , 5 Atypical wounds are often complex and require a collaborative approach, with the expert WOCNCB certified wound care nurse as a key member of the team.

Preparation for the WOCNCB wound care examination should include a review of the more common atypical wounds. Pay careful attention to the unique presentation of these wounds and the relationship of wound development and healing related to the underlying disease etiology. Useful tools when preparing for the WOCNCB wound care examinations are the Self-Assessment Examination (SAE) and Wound Care Flash Cards.6 Access to both of these tools can be found on the WOCNCB Web site (https://www.wocncb.org).

1. Tang J, Vivas A, Rey A, Kirsner R, Romanelli P. Atypical ulcers: wound biopsy results from a University World Pathology Service. Ostomy Wound Manage. 2012;58(6):20–29.

2. Wolf K, Johnon R, Saavegra A, Roh E. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. New York, NY: McGraw Hill; 2013:349–351.

3. Agarwal A, Cardones AR. Wounds caused by dermatologic conditions. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:573–585.

4. Pieper B. Atypical lower extremity wounds. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:515–529.

5. Bauer C. Oncology-related skin and wound care. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:587–610.

6. Wound Ostomy Continence Nursing Certification Board. Flash Cards. https://www.wocncb.org/certification/exam-preparation/flash-cards. Accessed March 16, 2018.

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PRACTICE QUESTIONS

1. Which of the following are key management strategies in treating calciphylaxis?

  1. Pain management, sharp debridement, and warfarin
  2. Sharp debridement, corticosteroids, and calcium supplement
  3. Corticosteroids and avoiding warfarin and trauma
  4. Pain management, underlying disease management, and avoiding trauma

Outline location: Domain 1; Task 7; Skill 010705

Cognitive level: Application

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ANSWER: D

Rationale: Effective treatment of calciphylaxis focuses on management of the underlying condition of renal disease along with supportive care that involves pain control and infection prevention. Caring for the underlying condition entails minimizing calcium intake to control the calcium-phosphate-parathyroid hormone axis. Impaired renal function in which the glomerular filtration rate reaches 25% or less creates imbalances in calcium and phosphate levels, leading to hyperparathyroidism, as the initial low serum calcium levels stimulate the parathyroid hormone. As a consequence of prolonged hyperparathyroidism, in conjunction with low vitamin D levels, soft tissue and vascular calcifications can develop. Additional measures in managing calciphylaxis include avoidance of aggravating factors such as trauma and warfarin, along with wound care measures for pain control and infection prevention. When choosing the correct answer option in a question like this one, a helpful strategy would be to mentally cross out the treatment modalities that are not recommended or appropriate. For example, in answer option “a,” 2 of the 3 treatment strategies are not appropriate, warfarin and sharp debridement. In answer options “b” and “c,” corticosteroids are listed as a treatment option. Local or systemic corticosteroids are not recommended and may even exacerbate the condition.

1. Pieper B. Atypical lower extremity wounds. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:515–529.

2. Heuther S, Forshee B. Alterations of renal and urinary tract function. In: McCance KL, Huether SE, Brashers VL, Rote NS, eds. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby; 2010:1365–1394.

2. When caring for a 30-year-old man with Stevens-Johnson syndrome, what topical dressing should be considered?

  1. Petrolatum contact layer dressing
  2. An occlusive transparent dressing
  3. Dry gauze with no contact layer
  4. Hydrocolloid dressing

Outline location: Domain 1; Task 7; Skill 010705

Cognitive level: Application

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ANSWER: A

Rationale: Stevens-Johnson syndrome is characterized by extensive necrosis and detachment of the epidermis, causing large amounts of transcutaneous fluid loss. Principles of moist wound healing and fluid management should be used with topical therapy. A nonadherent contact layer dressing such as petrolatum will help avoid trauma to the wound bed and limit discomfort with removal of dressings. Additional dressings used should absorb moisture while maintaining a moist wound environment. Nonadherent securing methods should also be used to avoid further trauma with dressing removal. An occlusive transparent dressing will not adequately manage moisture. While dry gauze may manage moisture, there is risk for further trauma to skin with removal if used without a contact layer. Hydrocolloid dressings may provide light to moderate moisture management yet would be an inappropriate option since it is an adhesive dressing.

1. Agarwal A, Cardones AR. Wounds caused by dermatologic conditions. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:573–585.

2. Wolf K, Johnson R, Saavedra A, Roh E. Fitzpatrick's Color Atlas and Synopsis of Clinical Dermatology. New York, NY: McGraw Hill; 2013:136–140.

3. A 30-year-old female cosmetologist presents with recent onset of reddened patches and multiple painful, oozing vesicles over her hands. Affected area is localized to the dorsum, fingertips, and interdigital web spaces of hands. Her nails are unaffected. What should the wound care nurse look for when reviewing the patient's history and assessment?

  1. History of childhood chicken pox
  2. History of psoriasis or eczema
  3. Recent change in soap, creams, or shampoo
  4. Recent change in medications

Outline location: Domain 1; Task 7; Skill 010702

Cognitive level: Knowledge

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ANSWER: C

Rationale: Acute irritant contact dermatitis occurs when an irritant, chemical or physical agent, disrupts the topmost layer of the epidermis, thus leading to loss of skin barrier. In this case, a change in soaps, creams, or shampoos should be looked for when reviewing the patient's history. Consider in this question, the patient is a cosmetologist. Irritant contact dermatitis is the most common type of occupational skin conditions. The patient is at a high risk for exposure to chemical irritants, and the location of a rash limited to the hands is a key clue. While eczema may present with reddened and vesicular patches, this condition is often pruritic. The question stem does not describe the patches and vesicles as being pruritic. Irritant contact dermatitis is more likely characterized by burning or pain than pruritus complaints. Psoriasis is characterized by plaques with silver scaling, with the nails often affected. Lesions are typically located on the scalp, back, and extensor surfaces of the elbows and knees. The question stem only describes lesions on the hands. A history of chicken pox would raise a red flag for possible herpes zoster. The question stem only refers to lesion on the hands where herpes zoster presents unilaterally and runs along a dermatome. Cutaneous drug reactions from a recent medication change will present as a generalized rash with hands less commonly affected.

1. Agarwal A, Cardones AR. Wounds caused by dermatologic conditions. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:573–585.

2. Habif TP, Campbell JL, Chapman MS, Dinulos JG, Zug KA. Skin Disease Diagnosis & Treatment. 3rd ed. Edinburgh, England: Elsevier Saunders; 2011.

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ADVANCED PRACTICE QUESTIONS

4. The advanced practice registered nurse (APRN) is managing a patient who has a painful lower extremity wound with a necrotic wound bed and raised violaceous edges. A culture and sensitivity test was negative for infection, and a biopsy showed nonspecific findings but included neutrophilic inflammation. The patient has also reported abdominal pains and diarrhea lasting for the past 5 months along with a 20-lb weight loss. Which of the following should the APRN consider next?

  1. Order a fiber supplement.
  2. Refer the patient to gastrointestinal services for a colonoscopy.
  3. Start the patient on loperamide.
  4. Start the patient on corticosteroids.

Outline location: 1A; 2B; 4D

Cognitive level: Analysis

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ANSWER: B

Rationale: The wound description in the question stem is consistent with that of a pyoderma gangrenosum. While the pathogenesis of pyoderma gangrenosum is not well understood, it is often associated with autoimmune conditions. Many patients with pyoderma gangrenosum have systemic inflammatory comorbidities, with inflammatory bowel disease being the most common. As this patient is presenting with chronic diarrhea and abdominal pain that is accompanied by weight loss, the patient should be further evaluated for inflammatory bowel disease. While increasing fiber may help bulk stool, chronic diarrhea that is unexplained will warrant further evaluation. Loperamide may help slow the patient's diarrhea; the cause of diarrhea and weight loss will remain unknown. Corticosteroids would be an appropriate treatment of pyoderma gangrenosum; however, the APRN must address the patient's weight loss, diarrhea, and abdominal pain as a first step.

1. Pieper B. Atypical lower extremity wounds. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:515–529.

2. Fletcher P, Solderitsch D. Granulomatous and neutrophilic disorders. In: Bobonich MA, Nolen ME, eds. Dermatology for Advanced Practice Clinicians. Philadelphia, PA: Wolters Kluwer; 2015:325–327.

5. A 62-year-old patient has a nonhealing ulceration of the upper right arm that started as a “scrape.” The patient was referred to the wound clinic when topical and systemic antibiotics were not successful in healing the wound. Since the patient has begun treatment at the wound clinic, optimal topical management has been utilized to maintain a moist wound-healing environment with still no improvement in the wound. What is the next step in the treatment of this wound?

  1. Obtain a wound culture.
  2. Obtain a radiograph of the right arm.
  3. Obtain a biopsy sample of the wound.
  4. Check the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

Outline location: 1A; 1C; 2B

Cognitive level: Application

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ANSWER: C

Rationale: This wound presents in an atypical manner with an unclear etiology. Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) can present as chronic wounds. The location of the wound being in a sun-exposed area such as an upper arm would raise suspicion for either SCC or BCC, as there has been no improvement in the wound even with optimal topical management. A biopsy to further evaluate for malignancy would be warranted.

A biopsy is the “gold standard” for diagnosis and the sample should be taken at the proximal or leading margin of the wound encompassing 50% of wound margin and 50% of adjacent tissue. An additional tissue sample should be taken within the wound bed. All tissue samples must be properly labeled. This patient has completed both topical and systemic antibiotics with no improvement prior to being seen at the clinic. A culture and sensitivity test would be indicated for signs and symptoms of infection including erythema, warmth, swelling, increased pain, drainage, and odor. None of these were indicated within the question. Though a radiograph may show soft tissue swelling or bone involvement, this test is not highly sensitive and the probability of bone involvement is low based on the wound assessment and lack of additional signs and symptoms. Checking an ESR and CRP will show inflammation and is highly sensitive; however, it is not a specific test and further evaluation would be needed.

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REFERENCES

1. Pieper B. Atypical lower extremity wounds. In: Doughty DB, McNichol LL, eds. Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:515–529.
    2. Stallard Y. When and how to perform cultures on chronic wounds? J Wound Ostomy Continence Nurs. 2018;45(2):170–186.
      3. Kent D. Wound care. In: Dermatology for Advanced Practice Clinicians. Philadelphia, PA: Wolters Kluwer; 2015:356–361.
        © 2018 by the Wound, Ostomy and Continence Nurses Society.